- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,843.77 / $1,843.77 / $1,843.77
| Facility | | $1,843.77 | $1,843.77 | $1,843.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.77 / $1,843.77 / $2,392.54
| Professional | | $1,843.77 | $1,843.77 | $2,392.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,135.69 / $7,075.57 / $22,374.02
| Facility | | $2,135.69 | $7,075.57 | $22,374.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.38 / $2,795.23 / $4,120.93
| Professional | | $1,648.38 | $2,795.23 | $4,120.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,478.92 / $5,449.12 / $7,017.43
| Facility | | $4,478.92 | $5,449.12 | $7,017.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.21 / $3,253.15 / $3,253.15
| Professional | | $2,763.21 | $3,253.15 | $3,253.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,440.87 / $2,507.59 / $2,958.36
| Facility | | $2,440.87 | $2,507.59 | $2,958.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $4,494.00
| Professional | | $1,830.54 | $2,507.59 | $4,494.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,416.61 / $3,416.61 / $3,587.44
| Professional | | $3,416.61 | $3,416.61 | $3,587.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.01 / $2,634.01 / $2,634.01
| Professional | | $2,634.01 | $2,634.01 | $2,634.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,876.27 / $22,374.02 / $22,374.02
| Facility | | $8,876.27 | $22,374.02 | $22,374.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,468.71 / $2,105.23 / $4,120.93
| Professional | | $1,468.71 | $2,105.23 | $4,120.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.73 / $2,105.23 / $3,532.74
| Professional | | $1,493.73 | $2,105.23 | $3,532.74 |